Sec. 53-441. Definitions. As used in sections 53-440 to 53-443, inclusive:

(a) “Statement” includes but is not limited to any notice, statement, invoice, account, bill for services, explanation of services, medical opinion, test result, computer generated document, electronic transmission or other evidence of loss, injury or expense;

(c) “Insurer” means any insurance company, health care center, corporation, Lloyd’s insurer, fraternal benefit society or any other legal entity authorized to provide health care benefits in this state, including benefits provided under health insurance, disability insurance, workers’ compensation and automobile insurance or any person, partnership, association or legal entity which is self-insured and provides health care benefits to its employees or governmental entity which provides medical benefits to Medicare or Medicaid recipients.

(P.A. 87-481, S. 2; P.A. 93-430, S. 2; P.A. 95-79, S. 181, 189.)

History: P.A. 93-430 amended the definition of “statement” to include “electronic transmission” and changed the definition of “health care insurer” to “insurer” and included health care centers and governmental entities providing medical benefits to Medicare and Medicaid recipients and added reference to the benefits provided under health insurance, disability insurance, workers’ compensation and automobile insurance to the definition of “insurer”; P.A. 95-79 redefined “person” to include a limited liability company, effective May 31, 1995.

Sec. 53-442. Health insurance fraud. A person is guilty of health insurance fraud when he, with the intent to defraud or deceive any insurer, (1) presents or causes to be presented to any insurer or any agent thereof any written or oral statement as part of or in support of an application for any policy of insurance or claim for payment or other benefit from a plan providing health care benefits, whether for himself, a family member or a third party, knowing that such statement contains any false, incomplete, deceptive or misleading information concerning any fact or thing material to such claim or application, or omits information concerning any fact or thing material to such claim or application, or (2) assists, abets, solicits or conspires with another to prepare or present any written or oral statement to any insurer or any agent thereof, in connection with, or in support of, an application for any policy of insurance or claim for payment or other benefit from a plan providing health care benefits knowing that such statement contains any false, deceptive or misleading information concerning any fact or thing material to such application or claim. For purposes of this section, “misleading information” includes but is not limited to falsely representing that goods or services were medically necessary in accordance with professionally accepted standards.

(P.A. 87-481, S. 3; P.A. 93-430, S. 3.)

History: P.A. 93-430 deleted references to “health care insurer” and substituted “insurer” in lieu thereof, included a reference to application for “policy of insurance” in lieu of “application” and added a provision re assisting, abetting, soliciting or conspiring to defraud an insurer or any agent thereof.

Sec. 53-443. Penalty. Order of restitution. Attorneys’ fees and investigation costs included in restitution. Any person who violates any provision of sections 53-440 to 53-443, inclusive, shall be subject to the penalties for larceny under sections 53a-122 to 53a-125b, inclusive. Each act shall be considered a separate offense. In addition to any fine or term of imprisonment imposed, including any order of probation, any such person shall make restitution to an aggrieved insurer, including reasonable attorneys’ fees and investigation costs.

(P.A. 87-481, S. 4; P.A. 93-430, S. 4.)

History: P.A. 93-430 specified that each act of fraud constitutes a separate offense and included reasonable attorneys’ fees and investigation costs in the restitution order.

Sec. 53-444. Cause of action, when. Any insurer, as defined in subsection (c) of section 53-441, that is aggrieved as a result of an act of insurance fraud may institute an action against the perpetrator of such fraud to recover all damages resulting from the fraud.

Sec. 53-445. Knowledge of health insurance fraud, report to Insurance Commissioner. Independent investigation conducted. Subject to civil liability, when. (a) Any person, including an insurer, as defined in subsection (c) of section 53-441, who has knowledge of or has reason to believe that health insurance fraud, as defined in section 53-442, has occurred, shall provide notice and any information, evidence and documentation in the person’s or its possession relative to the suspected fraud to the Insurance Commissioner.

(b) The commissioner shall review and investigate any reports of or information received by any person regarding insurance fraud; he shall conduct an independent investigation of the suspected insurance fraud; and when he reasonably believes that a violation has occurred, he shall refer such investigation to the appropriate state agency for criminal prosecution, civil enforcement or disciplinary action. During the commissioner’s investigation and prior to the referral of such investigation, the investigation and record thereof shall be confidential.

(c) Any person, including an insurer, as defined in subsection (c) of section 53-441, or a not-for-profit organization established to detect and prevent insurance fraud or his or its agents or employees may disclose otherwise personal or privileged information as defined in section 38a-976, orally or in writing to another person concerning any alleged, suspected or anticipated insurance fraud as defined in section 53-442, when such disclosure is limited to that which is reasonably necessary to detect, investigate or prevent criminal activity, fraud, material misrepresentation or material nondisclosure.

(d) No person shall be subject to liability for libel, slander or any other civil liability in connection with the filing of reports or documents, or furnishing orally or in writing information concerning any suspected, anticipated or alleged insurance fraud, when the reports, documents or information are provided or received in accordance with the provisions of subsection (a) or (c) of this section or in accordance with an order issued by a court of competent jurisdiction to provide testimony or evidence, unless such person disclosed false information with malice or wilful intent to injure any person.

(P.A. 93-430, S. 7, 9; P.A. 00-211, S. 5.)

History: P.A. 93-430 effective October 1, 1994 (Revisor’s note: In subsections (a) and (c) the words “their possession” and “their agents” were changed editorially by the Revisors to “his or its possession” and “his or its agents” respectively, for grammatical correctness); P.A. 00-211 amended Subsec. (a) to require notice and evidence in a person’s possession relative to suspected fraud to be provided to the Insurance Commissioner, and made a technical change for purposes of gender neutrality.